Testing times for medical science

Dr Rob Morrison, a Professorial Fellow from Flinders University in Adelaide, is also the Vice President of Friends of Science in Medicine, an organisation that was formed to discourage universities from offering pseudoscientific health courses under a scientific banner and calling them evidence-based when they are not. The Australian Skeptics have named the Friends of Science in Medicine as 'Skeptic of the Year'. This year's winner of the Australian Skeptics' Bent Spoon award 'for the most preposterous piece of paranormal or pseudoscientific piffle' went to Fran Sheffield from Homeopathy Plus. This organisation has made claims that homeopathy can help with the highly contagious bacterial disease of whooping cough and that vaccine is ineffective against a new strain of that disease.

Transcript

Robyn Williams: Last weekend the Australian Skeptics chose their Skeptic of the Year and you’re about to meet him, or them, for it’s an organisation formed to save us from flaky therapies or CAMS as they’re called, Complementary and Alternative Medicines, ones which cost Australia gigantic sums of money. Here’s Rob Morrison, who’s a Professorial Fellow at Flinders University in Adelaide.

Rob Morrison: Late in 2011 Friends of Science in Medicine formed in Australia to discourage universities from offering pseudoscientific health courses under a scientific banner and calling them evidence-based when they are not. It also hopes to convince governments that taxpayers’ money should not be spent in funding these courses or in rebates for spurious health treatments. I must immediately declare an interest in that I am one of the five founders of the group and currently its vice-president.

Within a few weeks we had hundreds of supporters and media coverage in Australia, the USA and the UK where the government recently ceased funding pseudoscientific health courses in British universities. Subsequently the Australian federal budget announced a review of Complementary and Alternative Medicines to identify those which are not evidence-based and should no longer receive taxpayer funded rebates. Among those listed are homeopathy, reiki, aromatherapy, ear candling, crystal therapy, flower essences, kinesiology and rolfing.

If you’re interested in real science you probably don’t know what these claim to offer, so here’s a quick Cook’s tour of a few.

Homeopathy was dreamt up by Samuel Hahnemann in the 1700s. It’s based on the odd notion that a substance causing disease in healthy people will cure that disease in sick people. Homeopathic treatments are prepared by diluting the substance in water and striking the container; a process called ‘succussion’. The dilution may be so extreme that no original substance remains, but this is said to increase the remedy’s potency. Scientific research understandably shows that homeopathic remedies are ineffective and their postulated mechanisms implausible.

Three more CAMs created by gurus involved muscular and skeletal manipulation. They are rolfing, applied kinesiology and chiropractic. The last invented by DD Palmer in the 1890s involves an undetectable ‘energy’ within the backbone said to interfere with an ‘innate intelligence’ of the human nervous system to cause many diseases, which science has repeatedly shown have other causes and are not improved by chiropractic

The claim that unlikely parts of the body reveal or affect health in all of it is a feature of CAMs. Iridologists go for the iris of the eye, reflexologists the sole of the foot, while palmistry involves the palm of the hand. Aromatherapy adds the nose. You begin to wonder why phrenology, diagnosing character through bumps on the head, ever died out! As you can guess, scientific studies reveal all of these CAMs are baseless.

Yet another guru, more mysterious energy and new jargon surface in reiki. Originated in 1922 by a Japanese monk, this involves transferring ‘universal energy’ through the palms to create self-healing. Disciples debate whether to place palms systematically or intuitively but scientific evaluation shows both are ineffective.

Ear candling and crystal healing explain what they involve but not how burning candles in your ears or rubbing crystals on your body parts can conceivably cure anything. Once more, mysterious energies are called upon and these practices similarly fail scientific scrutiny.

One could list such CAMs all day as more are spawned each year. Like creating new religions, it is a lucrative field if you can claim to diagnose what others can’t, cure virtually anything and portray yourself as the only person with expertise to do so. If you also claim the right to call yourself ‘doctor’ as some have recently done, financial success is assured, especially if the long suffering taxpayer forks out for your treatments and training.

As every state struggles to afford effective medical equipment and resources your taxes are helping to pay for these spurious alternative treatments and training people in how to offer them, shockingly that training now offered in nearly one third of our universities.

CAM is a misleading term confusing clearly spurious alternative nonsense with some activities that can complement evidence-based treatment. Massage, relaxation, yoga, lifestyle advice and more add to a patient’s comfort and wellbeing without claiming to do much more. Most problems lurk in the alternative practices. Promoted as alternatives to conventional medicine, they offer procedures ranging from the bizarre to the dangerous and consistently fail to show any kind of efficacy when challenged by sound scientific analysis.

Friends of Science in Medicine (or FSM) applauds the long overdue scrutiny that at least some of these pseudosciences will now receive through the budget’s initiative, but there has been a predictable backlash. Furious supporters of alternative treatments are quick to react to the media and blog sites that argue for evidence-based health treatments.

These challenges reveal a consistent pattern. Dr Cameron Martin has identified eight of them. The first four are more or less dogmatic assertions. They are that pure science doesn’t apply to health which is individualistic; natural therapies are better than synthetic ones; CAMs have no side effects and even if they don’t work CAMs do no harm.

The remaining four offer at least a hint at an argued case. They are that – CAMs are popular so they must be good; CAM opponents are closed-minded; Many CAM procedures appear to work anecdotally and many medical treatments are unproven which makes other unproven treatments just as valid.

Some of these eight ‘defences’ defy common sense as well as science. The first four are demonstrably inaccurate while the remainder are really position statements, but the last claim in interesting.

The usual argument runs like this. CAMs are accused of not being evidence-based, but much conventional medicine is also not evidence-based, therefore CAMs don’t need to be evidence-based and hence CAMs are as good as conventional medicine. This often comes with a diatribe about doctors protecting their own patch and the indignant question as to why FSM doctors should say what works rather than CAM exponents.

The diatribe is easily dealt with. Many in FSM are scientists, not medical doctors, and FSM doesn’t argue for doctors to hold the position of guru, but for any treatment, orthodox or not, to be defensible not because of who says it works but because valid, independent scientific examination shows that it works.

In fact FSM argues that CAMs should be subjected to scientific research to show what does and doesn’t work and as for authoritative pronouncements it’s the CAMs that quote the untested declarations of individuals as the basis of their entire philosophies, such as those of chiropractic, homeopathy, Reiki and so on. The rest of the response has more interesting implications. What are the real differences between science and pseudoscience, what does ‘evidence-based’ mean and is it really as powerful a factor in medicine as scientists and doctors maintain?

Some medical practitioners do disregard the scientific underpinning of their discipline; even incorporating CAMs in their work, but renegades do not represent medicine as a whole any more than they do in other professions. It’s also true that some medicine is not strongly evidence-based, but there is a big difference between medical practitioners trying possible treatments that orthodox science suggests may work to see if they do and CAM practitioners insisting that their treatments will work, despite evidence that they don’t and cannot without overthrowing the sciences of chemistry, physics and physiology.

The difference between these approaches references the scientific method. A medical practitioner faced with an ailment whose cause is poorly understood and treatments uncertain may suggest the trial of some medicine. Rosacea is a good example. Known as the 'Curse of the Celts', this reddening of facial skin brings misery to its sufferers. It is responsible for the classic red nosed boozer in cartoons, for alcohol reveals but does not cause the condition.

What does cause it is a mystery. Various hypotheses suggest allergy, skin mites, heredity, temperature and more. This is entirely reasonable, as science requires a hypothesis to test. Initial testing may then involve prescribing antihistamines, dietary changes, cortisone or something else, each reasonably suggested by the orthodox sciences of physiology and pharmacology.

This is not using haphazard, ambiguous treatments on the basis of mystical or dogmatic theories but starts the experimental process of seeking some reasonable treatment that may improve the condition, revealing its pathological cause.

The scientific method condenses to the shorthand of: Observation>Hypothesis>Experiment>Results>Discussion>Conclusion and Publication. The end result if you’re lucky, adds to a theory which combines countless experimental results, explains the mechanism behind them all and allows accurate predictions. Germ theory, the theories of evolution, immunity and many more were all built in this way allowing modern medicine huge advances in overcoming disease and even creating new disciplines within science.

The classic story of penicillin encapsulates that process. The chance observation that mould inhibited bacterial colonies in a culture dish led to a hypothesis that the mould killed bacteria. Experiments showed that it did, supporting the factual hypothesis and biochemistry then showed how it did, validating the explanatory hypothesis. It advanced the germ theory of disease, clarifying distinctions between bacterial and viral infections and how to treat each.

That progression from observation through to theory is a scientific one. Medical practitioners in the initial stages groping for observations to link cause and effect may be early in the process but they are certainly not defying it.

The difference with CAMs is that they start at the wrong end with a theory. Whether it be the subluxations of chiropractic, acupuncture’s meridians or the undetectable mystical forces of reiki, the starting point is a theory in full detail, often delivered as the pronouncement of an individual or the alleged wisdom of some ancient or obscure civilisation. Spurious explanatory hypotheses may be hinted at, although being mystical they are untestable, but evidence of the treatment’s effectiveness, that is any factual hypothesis on which a theory ultimately depends, is lacking, has not been tested or, if it has, is consistently shown by systematic experimentation to be invalid. In short the foundations that should underpin any theory were never in place before it was built.

The eight points of CAM defence admit that observations, such as they are, are selective and unashamedly partisan, while citing popularity and anecdotal accounts as evidence. CAM ‘theories’ defy orthodox science, relying on supernatural influences, spurning Ockham’s Razor and asserting that explanations contradicting fundamental physical and chemical laws deserve less, not more scientific scrutiny for their validation.

Publication, when and if it occurs, is also highly selective. High quality, peer reviewed journals seldom endorse CAM claims, they usually discredit them and the favourable reports of CAM treatments appear in the newsletters, website and textbooks of their practitioners, who have everything to gain by promoting their unorthodox treatments widely.

Science also builds its theories when the findings of different disciplines point in the same direction. Global warming is hugely complicated; analyses of ice cores, tree rings, coral growth, sea temperature, atmospheric composition and much more draw on the efforts of scientists in many diverse disciplines. When these highly disparate approaches lead to similar conclusions, it adds a level of agreement in a very complex business.

But CAMs produce no such conformity. How do chiropractic claims that human health is controlled by the spine reconcile with those of reflexologists (sole of the foot), iridologists (iris of the eye) and even palmists (palm of the hand)? Is that mysterious undetectable energy of chiropractors the same as that of the Reiki practitioner, the crystal healer and the acupuncturist? Why then does it behave so differently for each practitioner? How do you explain it when you can’t actually define, detect or measure any energy at all? That sort of problem is settled by science. It is not settled by self description on a website.

In short tentative treatments that produce observations and then test them scientifically to build an evidence-based theory are the reverse of procedures that start with a proclaimed theory but refuse to, and cannot, establish the facts that the theory attempts to explain and on which a truly scientific theory absolutely depends.

But confusing a terminology is one thing, confusing science with pseudoscience is quite another.

Robyn Williams: Dr Rob Morrison. He’s Professorial Fellow at Flinders University in Adelaide and also vice-president of Friends of Science in Medicine. They’ve just been named, last weekend, as Skeptic of the Year in Australia.

Next week Dr Peter Underwood from Western Australia takes us to Hiroshima.

Guests

Dr Rob Morrison

Professorial FellowFlinders UniversityAdelaideVice President of Friends of Science in Medicine

Credits

Presenter

Robyn Williams

Producer

Brigitte Seega

Comments (34)

Glenda Freeman :

09 Dec 2012 10:10:42am

Although I am a skeptic, I have used chiropractic to relieve the pain of osteoarthritis for over 10 years. I am also skeptical of orthodox medicine, having been wrongly diagnosed many times throughout my life (ie, 3 doctors told me I had a fungal infection which turned out to be a contact dermatitis due to a metal allergy, a surgeon told me I must have my womb removed for a problem which turned out to be gall stones). To be honest, I don't care if chiropractic theories are proven, I care if it relieves my pain, which it does.

Another Sue :

09 Dec 2012 6:37:01pm

It's true that there is a real difference between the various "CAM" modalities - chiropractic is a form of manipulative therapy, whereas homeopathy is no therapy at all (except perhaps reassurance). The important thing about chiropractic though, is that its origins include the concept of "subluxation", in which adjustments of the spine are said to cure problems in all organ systems, even in newborns. Modern chiropractors tend not to follow this paradigm, though some still do. Some are still openly anti-vaccination as well. If chiropractic is used as manipulative therapy, it is as effective as physiotherapy for conditions such as low back pain.

Of course errors occur in every human service. Errors made by medical practitioners do not make non-science-based therapies any more credible - or effective.

Joanne B :

09 Dec 2012 10:04:42pm

You may well have reason for being critical of some of the medical treatment you received - but that is not a valid reason for being skeptical of the science which underpins medicine itself. Regarding the benefit you have received from chiropractic, that is a positive outcome for you, but in itself is not evidence for the claims made by many chiropractors.

Marius :

10 Dec 2012 6:28:03pm

This is akin to saying "I'm not a racist, but.. (insert blatant racism).Many pre-scientific cultures used blood sacrifices to ensure good health. When good heath ensued, obviously it was because the gods were pleased. Correlation is not necessarily causation, particularly when dealing with dark arts like chiropractic (Straight chiro. Subluxations et al. Not the version that uses actual evidence based principles, like physiotherapy.) and homoeopathy, which have zero basis in reality.

There are two possibilities.1) Placebo2) There was no pre-existing physical condition.

Society needs less of this medievalist nonsense. It is to the great detriment of us all.

Sue :

09 Dec 2012 1:24:27pm

Some of this talk was reasonable, although delivered with a rather superior attitude, unfortunately still found in some doctors of medicine.However, I was annoyed by the linking of chiropractic treatment with homeopathic remedies as these are so different in theory and practice.I would like to suggest that, as sceptic of the year, he applies that scepticism to much of the research produced by universities in this era of commercially-driven funding. Over many years of working in the university system I have observed the quality and rigour of this research deteriorate as researchers seek to prove hypotheses rather than investigating opposing theories that might interfere with the proposed outcomes that they wish to claim.I have remained optimistic that pure research, such as found within the CSIRO, was still occurring within the scientific and medical disciplines but my optimism wanes with the falling research funding from the governement.

Joanne B :

Mark :

09 Dec 2012 10:13:26pm

Piltdown man was suspected a fraud quite soon after its "discovery". I hope you realise that it was scientists who proved it was a fraud using science, the same system that has proven homeopathy and many chiropractic claims to be fraudulent.

I wonder why chiroprators exist, after all we have medically trained people who do a similar thing called physiotherapists. I guess physios just know that cracking a neck won't fix all illness.

Luke Freeman :

Science also used the scientific method to figure out that Piltdown Man was a hoax and then self corrected.

The scientific method has been applied to a lot of SCAM (supplements, complementary and alternative medicine) and been shown to be lacking.

That is the point of a double-blinded clinical trial with replications. It shows if there is an actual effect on human beings.

If things go through many rigerous trials and still have negative results then they simply are not efficacious (putting it nicely).

The essential argument is that we should hold a high standard for both conventional medicine (which has problems) and SCAM. A good analogy for most SCAMs is when Doctors used to bleed patients (bloodletting) to try and cure them from any illness; we stopped them doing it because it was proven not to work and to actually cause harm.

Chris :

13 Dec 2012 2:12:55pm

Not to distract from your well-constructed logical arguments, but blood-letting is still an excellent treatment for haemochromatosis, polycythaemia rubra vera, and in a pinch, congestive cardiac failure... :-)

Liam :

10 Dec 2012 6:15:11pm

Fallibility is not the issue here. With piltdown man, the skeptics came through for us. most alternative medicines are just straight up 'not evidence based'. Most claims made by those who practice pseudoscientific alternative medicine either have not been proven to work, or have been proven to not work. yet the claims are still made.

Piltdown man would be a good analogy only if AFTER it was shown to be a hoax, it's classification remained, and we didn't disown it.

Marius :

David R Allen :

09 Dec 2012 3:14:07pm

Wonderful listen.

Simon Singh, a British science writer published an article on Chiropractory in the UK in a similar vain to this broadcast and got sued. He won, with the defense of "fair comment" but the outrage was so great, that it prompted libel law reform in Britain which has the most dangerous libel laws in the west. Wonderful that a law suit based on science was able to get libel law reform happening in the UK, where no other initiative or politic was able.

gardengranny :

10 Dec 2012 7:31:35am

Unfortunately many people don't realise that their doctor often can't make an accurate diagnosis in the few minutes of contact they have - the doctor must go through a process of elimination, trying different tests and treatments to work slowly towards (hopefully)accurate diagnosis and treatment. And of course even this isn't always possible as medicine still doesn't have all the answers, and doctors are only human beings, too. Small wonder patients are happier to believe in someone who can instantly 'diagnose and treat' their condition. My own doctor has lost patients because he refuses to prescribe antibiotics for everything! Perhaps it's time the medical profession worked a bit harder on a realistic public understanding of how medicine works.

David Cohan :

doug :

10 Dec 2012 7:37:56am

Hi Glenda and Sue,I too am a skeptic and I am frustrated by this same issue of grouping all of these therapies under the same umbrella. To compare the established evidence base for say, chiropractic (especially for neck pain, back pain and headaches) with that of palmistry or iridology is far from being 'scientific'. My understanding is that this is why the Australian Medical Association withdrew their support from Friends of Science in medicine.

The Australian Skeptics should have given the award to Dr. Ken Harvey for the work he is doing with the TGA and Medicines Australia.

David R Allen :

10 Dec 2012 6:34:55pm

Doug. Can you point to the evidence in support of chiropractic. As far as I know there is none. When a chiropractor manipulates some area of your body, the positive results are a collateral by product of accidental physiotherapy. You can't re-align a spine. All of the sinew, cartilage and muscle prevent that. Try it on the next fresh chicken you have. A physio can over a period of treatment, stretch the connective tissue to produce a result.

Sue. Your chiropractor is doing accidental physio. Seek out a good physio and you will get better results.

Doug :

11 Dec 2012 12:17:51pm

Of course there is evidence. Not even friends of science in medicine deny that.I have been to physios and chiros for my back and I can tell you from experience that they are different. And both help. Chiropractor is way more hands on and more likely to manipulate and physios mainly give exercises and are less likely to manipulate. Ask the average punter, I bet they will tell you there is a difference between the two. chiros aren't just doing 'accidental physio', any more than physios are doing 'accidental chiro'

David R Allen :

11 Dec 2012 5:32:47pm

Doug. I was actually hoping that you could point me to some published peer reviewed literature that supports your assertion that chiropractic is evidence based. Your assertion is nothing. Show me the evidence.You might like to read my post above about Simon Singh who was sued by the British Chiropractic Association for asking the very same question that Rob Morrison asked in his presentation, and I ask of you. Where is the evidence. The British Chiropractic Association withdrew their suit, because they could not support the assertions on their web page with evidence. So if you have evidence, then the whole world will be stunned to read it.

doug :

12 Dec 2012 2:20:47pm

David,The evidence is there, you just need to look. As I have said previously, for back pain,neck pain, headaches and other musculoskeletal problems there is evidence supporting chiropractic care. Unless of course you think FSM are incorrect too. The problem with us skeptics is that we have, for so long, bagged chiro's that we are now too afraid to actually say that they do help with some things. So instead of admitting it and accepting the evidence, we say things like they are doing 'accidental physio' instead. We are kind of giving them a backhanded compliment.

and BTW, the chiro's didn't drop the case against sinmon singh because the BCA couldn't prove their assertions, they were never asked to by the courts. They dropped the case because the court decided that Simon didn't have to prove his. And it was a sensible judgement, people should be allowed to express their opinion based on their interpretation of evidence.

Stewiegriffin81 :

12 Dec 2012 8:46:54pm

Doug is making claims that are far too strong for the evidence that actually exists. There is no strong evidence supporting chiropractic for any condition. There is very weak evidence supporting chiropractic for a handful of musculoskeletal conditions (such as non-specific chronic back pain), but none of it is sufficient to satisfactorily demonstrate that it actually works beyond placebo.

David R Allen :

13 Dec 2012 8:24:24am

Doug. You claim the title of "Skeptic". A skeptic is a person whose opinion is guided by evidence. If the evidence changes the persons opinion follows the evidence. If there is no evidence to support a position, a skeptic will not support that position.You are asserting, without evidence that chiropractic is evidence based. I have asked you to support your claim but you have failed twice.I am a skeptic and my opinion is guided by the evidence.

Chiropractic relies on a concept called "Subluxations". That is, manipulation of the spine increases nerve flow that cures illness. Here is what the Skeptics say on Subluxation.

"The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns."

The full dismissal of chiropractic by the skeptics can be found here.http://www.skepdic.com/chiro.html

Your choice Doug, is to either be a Skeptic, and reject chiropractic, or believe on faith, that something without evidence works. People believing on faith in something is called religion.

Doug :

13 Dec 2012 2:16:40pm

David,What evidence will you accept?

While we are on the topic of skeptic supporting their positions with evidence can you point me in the direction of the evidence that support your health care advice that people will get better results with physio than a chiro for back pain.

doug :

16 Dec 2012 8:45:30am

Hi David,Thanks for the link.

I used the pedro search engine that you provided a link to. I simply plugged in Chiropractic to the search engine. I then did the same for physiotherapy. It appears that most of the conclusions and recommendations seem consistent across the board for low back pain, neck pain, certain headache types (particularly migraine and TTH)and some musculoskeletal problems. Studies consistently show low to moderate quality evidence for the effectiveness for a range of different techniques across professions for treating people with these conditions. No intervention seems to be particularly more helpful than any other. More studies would be helpful, particularly in the area of subtyping patients prior to therapy.

What I didn't find is a large body of evidence that would allow advice suggesting the physiotherapy would provide more benefit than chiropractic in the treatment of back pain. Indeed there is some that suggests the reverse.

It would be reasonable to conclude that using an evidence-based (or evidence informed) approach to management of patients with the conditions mentioned above ie; that is, taking into account the best, currently available evidence; drawing on the treating practitioners experience; and taking into account the patient's preferences for treatment, either physiotherapy or chiropractic would be an appropriate intervention.

Skepticism is about 'seeking the evidence', I will keep my badge and continue to do just that.

Juliette :

28 Dec 2012 3:58:09am

Quick question. How do you all feel about physiotherapists performing adjustments or manipulations on patients? Why is it that when a physio does manipulates, it's ok? Despite having less training in the area than Chiropractors. And when a Chiropractor does it, it's a sham treatment? Simply non-EBP.

Will medicine one day shun physiotherapy due to the integration of manipulative therapies? Or has it been that physiotherapist have realised that there is efficacy in manipulative therapy and decided to incorporate this into their arsenal?

I realise my post was mostly questions, but I do believe that these are important.

Peter :

13 Dec 2012 8:05:59pm

As a follower of The Health Report on Radio National, it has become apparent to me that the Skeptics are selective about what they choose to be skeptical about. As we heard on the program on SSRI anti-depressants (Mayberg HS et al. The Functional Neuroanatomy of the Placebo Effect. American Journal of Psychiatry 2002;159:728-737), for most people with moderate depression SSRI's work no better than placebo. There have been other examples like this on the the program like the overinflated claims made for the effectiveness of flu vaccine (27 April 2009). When evidence of efficacy of non establishment treatments such as treatment of influenza with Chinese medicine are shown (22 August 2011), they are completely ignored.

David R Allen :

16 Dec 2012 3:33:47pm

Peter. I note your very accurate reference to a scientific paper on SSRI's. Could you please supply me with a corresponding reference for you assertion in relation to Chinese medicines, (22 August 2011) I would be interested to read the scientific proof of your claim.

Anthony :

22 Dec 2012 10:06:55am

This influenza study was unblinded and has not been reproduced. It also uses mixtures of chinese herbal medicines that may contain other elements which have not been fully analysed. These are red flags that more study needs to be done before any credence can be given. The antidepressant study has been reproduced and the reason you know about it is that scientists have made the medical community aware that there is some question as to the efficacy of these antidepressants in mild or moderate depression.

Peter :

25 Dec 2012 6:36:44pm

I agree, more studies would be good but are unlikely if the FSM have their way and have Uni research funding withdrawn. Re antidepressants, the reason I know there is a question as to their efficacy is because someone went to the trouble of using freedom of information legislation to look at the less impressive trials. I would suggest that this rarely happens. But now we have this information has the use of SSRI's decreased?